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_ n <br /> WELUPUMP PERMIT ��LEVED <br /> SAN JOAOWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT C LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 x ` rn <br /> JOB ADDRESS 1 ✓V 1 ( CITY <br /> IZIP 1� m <br /> ` D <br /> CROSS STREET C L�IrrU�IO!1 i AP ,Z Y S'��O�taC PARCEL SIZE IJ ND USE APPLICATION a A <br /> OWNER NAME EC%L Ni L\-,G'\ PHONE <br /> OWNER ADDRESS �r7 CIT1'/STTATE/ZIP t, sa1r K t "151(--c <br /> CONTRACTOR P6 ar <br /> + 'N�� U /A1 PHONE f1'��� <br /> CONTRACTOR ADDRESS iDVt!„y �[?W eJ�J �'Fli� CITY/STATE/U � <br /> P �X4%c^ I CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C+ITYISTATEZP <br /> LICENSE n(C-57 !C-61 D-09 r Other NUMBER ExPIRAnON DATE '3 i <br /> DOMESTIC WELL SAMPLING:,-I General MineraVColiform Bacteria(4391) Dibromochloropropane(4392),-j Arsenic(4393) <br /> INTENDED USE DomesticJPrivate -1 Irrigation/Agricultural -Industrial J Water Quality Monitoring /Soil Samplingicharacterization <br /> rT Public Water System <br /> It cnnerem horn Owner. Wafer Sy d—Name Conned Nunn w Phone Number <br /> TYPE OF WORK U New Well _�Replacement Well -,Well Alterabon7Modficafion L Other <br /> Monitoring Wells) If of wells n Soil Boring(s) R of borings Geotechnical #of borings <br /> LI Out-Of-Service Wee Out-Of-Service Wei Renewal Cross-Connection Repair <br /> New Purnip rii Pump Replacement n Pump Repair Raise Wel Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary R Air Rotary r Auger -i Cable Tool n Push Point n Other <br /> Proposed Well Depth it Excavation in diameter n Open Bottom ';Gravel PadUGravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell n Steel F Plastic n Stainless Steel Other <br /> Grout Seal Depth it n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mixr7 gal water <br /> n Bentonite(20%solids) r Other <br /> Grout Placement Method n Pumped n Free Fail 1 Other n Retardant I Accelerator(name) <br /> PEDESTAL Installed By �,Driller )(Pump Contractor ��- Other <br /> vQ Concrete Pedestal r'Dimensions:VV ft Length ft Th ck in r Christy Box -Stove Pipe <br /> PUMP Submersible L:Turbine -,Other HP - Pump Set \�eCl ft Standing Water Level_4Lft <br /> 1 HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 43(-TOUR ADVANCE NOTICE REQUIRED FOR`WISFECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE J T N_i r�j�C'e— _ DATE t� 41,;r�}�,,�q�rp spy. <br /> v1 <br /> el C <br /> b MAS? 0 5 2019 <br /> JOAQUIN COUNTY <br /> Ir4ONMENTAL <br /> H DEp,RTMENT <br /> c <br /> io <br /> i/eP A !;:t <br /> E N T7r.1N L Y L- Ar\,G+� \"�Q <br /> Application Accepted By mate f Area Employee ID# <br /> Date L PECIA Well Permit <br /> Grout Inspection By� �,��p <br /> Pump Inspection By[1' C�1ZiyA\U W\Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Permit/ Invoice# WellID# <br /> Co s Info uh emitted Se ice Re nest# <br /> }e9—Se 41WIS WELL IPUMF'PERMIT <br /> EHD 4 <br />